Dispatch of Helicopter Emergency Medical Services Via Advanced Automatic Collision Notification

BACKGROUND

Advanced automatic collision notification (AACN) is a system for predicting occupant injury from collision information. If the helicopter emergency medical services (HEMS) physician can be alerted by AACN, it may be possible to reduce the time to patient contact.

OBJECTIVE

The purpose of this study was to validate the feasibility of early HEMS dispatch via AACN.

METHODS

A full-scale validation study was conducted. A car equipped with AACN was made to collide with a wall. Immediately after the collision, the HEMS was alerted directly by the operation center, which received the information from AACN. Elapsed times were recorded and compared with those inferred from the normal, real-world HEMS emergency request process.

RESULTS

AACN information was sent to the operation center only 7 s after the collision; the HEMS was dispatched after 3 min. The helicopter landed at the temporary helipad 18 min later. Finally, medical intervention was started 21 min after the collision. Without AACN, it was estimated that the HEMS would be requested 14 min after the collision by fire department personnel. The start of treatment was estimated to be at 32 min, which was 11 min later than that associated with the use of AACN.

CONCLUSIONS

The dispatch of the HEMS using the AACN can shorten the start time of treatment for patients in motor vehicle collisions. This study demonstrated that it is feasible to automatically alert and activate the HEMS via AACN.

Characterization of in vitro biotransformation of the new oral anticoagulants, the factor VIIa inhibitors AS1927819-00 and AS1932804-00

We recently developed a prodrug (AS1932804-00, CMP) of the novel FVIIa inhibitor AS1924269-00, which possesses a carbamate amidine backbone. In addition, we developed another type of prodrug (AS1927819-00, OXP) with an oxime amidine backbone. In this study, we investigated the efficiency of conversion of these novel FVIIa prodrugs to their active forms by evaluating the production of the active form in vitro by using microsomes, mitochondria, and cryopreserved hepatocytes, and compared it with the in vivo conversion mechanisms of the prodrugs (oxime amidine vs. carbamate amidine). We observed that OXP and CMP showed improved oral absorption, and the efficiency of conversion of CMP to the active form was higher than that of OXP. The in vivo rate of conversion of OXP to its active form was low in rats, and compared to liver microsomes and mitochondria, cryopreserved hepatocytes supplemented with serum and coenzymes were an appropriate metabolic test tool. On the other hand, the efficiency of conversion of CMP to its active from could be appropriately evaluated using small intestinal microsomes. The development of a prodrug can be optimized when information about the stability of carboxylic acid esters in the presence of serum esterases, membrane permeability of intermediate forms, and differential tissue specificity to metabolic activities for carbamate and oxime backbones of amidine can be obtained.

Pharmacokinetics of the amidine prodrug of a novel oral anticoagulant factor VIIa inhibitor (AS1924269-00) in rats

AS1924269-00 is a promising orally applicable anticoagulant that inhibits FVIIa but has very low oral absorption. Therefore, in this study, we aimed to develop a prodrug of AS1924269-00, which possesses a carbamate-added amidine functional group, with high membrane permeability. We investigated the pharmacokinetics of the carbamate-type prodrug of AS1924269-00 in rats. The Caco-2 cell monolayer was used as an in vitro model and in parallel an artificial membrane permeability assay (PAMPA) was performed to examine the transport mechanisms of the prodrug. The bioavailability of the active form was determined to be only 0.3% in rats, but the oral absorption of the prodrug was markedly improved, and its bioavailability was 36%. Our in vivo result was consistent with the finding that compared to AS1924269-00, the prodrug showed favorable permeability in Caco-2 cells and PAMPA. We introduced carbamate into the amidine functional group of the FVIIa inhibitor, which possesses the amidine backbone, and converted it to a prodrug using carboxylic acid ethyl ester. This novel prodrug had favorable absorption and membrane permeability in vivo and in vitro. Thus, we suggest a clinical application of the carbamate-added amidine prodrug of the FVIIa inhibitor.

Development of an educational program for the helicopter emergency medical services in Japan

INTRODUCTION

The Japanese helicopter emergency medical service (HEMS) system provides advanced prehospital treatment at the scene. The education of the dispatched HEMS physicians is important for guaranteeing the quality of medical and safety management, but there is no nationally established training program. This study aimed to determine the validity of the HEMS educational program developed by our team.

METHODS

A 3-step educational program was designed for HEMS trainees: step 1, 20 HEMS missions as an observer; step 2, 80 missions of on-the-job training; and step 3, certifying examination conducted by a supervisor. As an evaluation standard, scene time, defined as time from landing at the scene to taking off for a hospital, was determined retrospectively.

RESULTS

For trainees, scene time was significantly longer (16.3 ± 5.4 min, 95% CI 15.5-17.1) than for experts (doctors who completed >200 HEMS missions; 15.2 ± 6.7 min, 95% CI 14.7-15.8; P = 0.040) but was significantly shorter than for doctors trained before establishment of the HEMS program (17.5 ± 7.0 min, 95% CI 16.9-18.2; P = 0.030). In cases of trauma or intrinsic disease, there was no significant difference in scene time between trainees (17.4 ± 5.6 min and 14.9 ± 4.8 min, respectively) and experts (16.4 ± 7.8 min and 14.2 ± 5.5 min, respectively).

CONCLUSION

The finding that scene time was shortened for program trainees demonstrates the validity of our HEMS educational program. The quality of HEMS missions will be better ensured through this educational system.

[A case of large vesicourethral stone resulting from long-term retention of a Foley catheter]

We report a case of a large vesicourethral stone resulting from a long-term indwelling urethral catheter. A 66-year-old man visited our hospital emergency room on October 24, 2006 with a chief complaint of difficult urination. Although a urethral catheter was inserted temporarily based on the diagnosis of the doctor on duty, the patient did not return to our hospital for follow-up examination. On July 10, 2008, he was wheeled into our hospital with symptoms of general fatigue, urinary retention and post-renal failure due to urethral catheter obstruction. The catheter was undisturbed, and computed tomography revealed a large bladder stone that extended along the lines of the catheter. A cystostomy was established, and after renal function had recovered, the bladder stone was completely removed via laparotomy following the transurethral approach. The stone consisted of magnesium ammonium phosphate and calcium phosphate. It was concluded that the stone was closely related to a urinary tract infection caused by a Proteus strain. We discuss this unusual case, which is characterized by the stone size and the clinical course.

[Solitary fibrous tumor of a kidney: a case report]

The patient was a 44-year-old woman who had undergone a medical examination because of a left kidney mass. A radical nephrectomy was performed under diagnosis of renal cell carcinoma. Microscopically tumor consisted of spindle-shaped cells accompanied by fibrous connective tissue. Immunohistochemically the tumor cells were diffusely positive for CD34, negative for HMB45 antigen and tyrosinase. The final diagnosis was solitary fibrous tumor.

[Transanal repair of rectourethral fistula after radical retropubic prostatectomy: a case report]

A 65-year-old man underwent a radical retropubic prostatectomy for prostate cancer, and 5 days later fecaluria and serous diarrhea appeared suddenly. Cystourethrography domonstrated the flow of contrast material into the rectum through the fistula, so we diagnosed a rectourethral fistula. We first attempted conservative management, but the fistula did not close spontaneously. So we performed the transanal repair of rectourethral fistula about 2 months after surgery. This repair was effective, and the patient was alive without fistula recurrence at about 2 years after the repair surgery. This approach is simple and does not require a new incision, but it is only useful for low rectourethral

Beta(3)-adrenoceptor agonists for the treatment of frequent urination and urinary incontinence: 2-[4-(2-[[(1S,2R)-2-hydroxy-2-(4-hydroxyphenyl)-1-methylethyl]amino]ethyl)phenoxy]-2-methylpropionic acid

In a search for novel analogues of beta(3)-adrenoceptor (AR) agonists relaxing the bladder for treatment of urinary dysfunction, 2-[4-(2-[[(1S,2R)-2-hydroxy-2-(4-hydroxyphenyl)-1-methylethyl]amino]ethyl)phenoxy]-2-methylpropionic acids (1a-e), into which a fibrate-like structure had been incorporated, were synthesised. Compound 1a was found to be a selective beta(3)-AR agonist in functional assays using the ferret detrusor (beta(3)-AR), rat uterus (beta(2)-AR), and rat atrium (beta(1)-AR); beta(3): EC(50)=7.8 nM, beta(2): IC(50)=7,300 nM, beta(1): EC(20)=23,000 nM. The introduction of a chlorine atom or methyl substituent at the ortho-position on the phenyl ring of 1a further improved beta(3)-AR selectivity. In an in vivo study, 1a lowered intrabladder pressure (ED(50)=31 microg/kg) in rats, without increasing heart rate, in keeping with the in vitro results. Consequently, it is proposed that 1a and its analogues (1b-e), possess beta(3)-AR agonistic activity in the absence of undesirable beta(1)- or beta(2)-AR mediated actions, and may be useful for clinical treatment and pharmacological studies.

Matrix effect on the analysis of oligonucleotides by using a mass spectrometer with a sonic spray ionization source

Matrix or impurities remaining in a DNA sample solution after various sample treatment procedures may influence a subsequent DNA analysis. In this work, several matrices were investigated concerning their effects on the analysis of oligonucleotide by using an ion-trap mass spectrometer equipped with a sonic spray ionization source. Inorganic salts of sodium chloride and magnesium chloride depressed the signal intensity by about 50% when the content of the salts was about 10 microM. dNTPs and Taq showed more severe depression on the oligonucleotide. However, Tris, or (hydroxymethyl)aminomethane, intensified the signal intensity, if its content was within an appropriate range. When the content of Tris was about 500 microM, the signal intensity was enhanced by factors of 3 and 5 for the 6-mer and the 20-mer oligonucleotides, respectively. With the existence of Tris, matrix effects from the inorganic salts, dNTPs and Taq were reduced.

Discovery of novel N-phenylglycine derivatives as potent and selective beta(3)-adrenoceptor agonists for the treatment of frequent urination and urinary incontinence

With a novel assay using isolated ferret detrusor to estimate beta(3)-adrenoceptor agonistic activity, we found that a series of glycine derivatives of ritodrine, a beta(2)-adrenoceptor agonist, are potent beta(3)-adrenoceptor agonists, with excellent selectivity versus beta(1) and beta(2) subtypes. Substitution of halogens in the phenyl ring increased potency and selectivity for the beta(3)-adrenoceptor, and this was dependent upon the position of the halogens. The chlorine-substituted derivatives 3f-i exhibited potent beta(3)-adrenoceptor-mediated relaxation of ferret detrusor (EC(50) = 0.93, 11, 14, and 160 nM) and higher potency at beta(3)-adrenoceptors than at beta(1) or beta(2). The intravenous administration of 3h significantly reduced the urinary bladder pressure in anesthetized male rats (ED(50) = 48 microg/kg) without cardiovascular side effects. This article is the first report of structure-activity relationships (SAR) concerning beta(3)-adrenoceptor agonists as agents for the treatment of urinary frequency and incontinence.

Error correcting memorization learning for noisy training examples

In order to avoid overfitting, we propose error correcting memorization learning. This method is derived from minimization of error between outputs of a trained neural network and correct values for noisy training examples, although the correct values are unknown. We show that noise is adequately suppressed by error correcting memorization learning. The noise suppression mechanism is theoretically clarified. It is found that redundancy plays an essential role for noise suppression and depends on a set of training inputs. We give the condition for the training inputs to provide the redundancy. Moreover, by clarifying the relationships between the proposed method and the weighted least squares estimation with the Mahalanobis norm, we reveal effectiveness of the weighted least squares estimation on noise suppression.

Repeated 131I treatment of a residual ovarian teratoma containing malignant thyroid tissue

A 49-year-old woman with ovarian teratoma received 131I treatment three times for an unresectable mass containing malignant thyroid tissue after surgery. Repeated 131I treatment effectively reduced serum thyroglobulin (Tg) level and tumour uptake of 131I, despite absence of any change in size of the treated tumour. Treatment did not inhibit the increase of serum CA-125 and tumour 201Tl uptake, associated with progression of a radioresistant intratumoral hyper-perfused tissue component, detected by colour Doppler ultrasound. Serum CA-125 level and tumour 201Tl uptake were not significantly changed despite temporary increases in serum Tg level after each 131I treatment. These observations indicate the importance of diagnostic measures using combined functional imaging and tumour markers in managing this rare tumour.

Tc-99m DTPA used as reference imaging to evaluate the distribution of other tumor-seeking tracers in tumors associated with neurofibromatosis

Two patients with multiple benign and malignant tumors associated with neurofibromatosis underwent radionuclide imaging with Tc-99m DTPA, Tl-201, and Ga-67. In these patients, Tc-99m DTPA accumulated intensively in both the benign and malignant tumors and localized and defined the extent of every tumor. In contrast, Ga-67 and Tl-201 uptake was seen only in focal areas of tumor where there was malignant transformation or at sites that showed progressive tumor growth. Tc-99m DTPA imaging accurately demonstrated areas of neoplastic involvement and identified the areas that would be seen with the other two tracers in individual tumors. Tc-99m DTPA may not always be used for the differential diagnosis of malignant and benign tumors of neurofibromatosis, but it can provide a reference pattern for imaging to evaluate accurately the distribution of Tl-201 and Ga-67 by mapping out the anatomic extent of these tumors.

Abnormal brain perfusion demonstrated by Tc-99m MAA total-body scan in two children with complex congenital heart disease

This paper describes abnormal brain perfusion unexpectedly demonstrated by Tc-99m MAA total-body imaging in two children with intracardiac right-to-left shunt (RLS) associated with complex congenital heart disease. One child was a 12-year-old girl with asplenia cardiac syndrome and multiple cerebral infarctions caused by thromboembolism in the internal carotid artery, and the other child was a 6-month-old boy who developed focal cerebral infarction following shunt operation. In both children, the total-body imaging depicted the brain due to RLS, where radioactivity decreased unilaterally in the cerebral hemisphere. In the first patient, radioactivity also decreased in the contralateral cerebellum, suggesting the crossed cerebellar diaschisis phenomenon. These abnormalities in brain perfusion were confirmed by Tc-99m HMPAO brain SPECT. Careful review of the distribution of the radiotracer in the depicted brain on Tc-99m MAA total-body imaging may provide important information regarding brain perfusion in some patients with a high risk of stroke complication associated with RLS.

Involvement of bacterial antigens in immunoglobulin A nephropathy

To investigate the involvement of bacterial antigens in Immunoglobulin A (IgA) nephropathy, we measured IgA, IgG and IgM antibodies to gram-negative Escherichia coli (E.coli) and Haemophilus influenzae (H.influenzae) by ELISA in 24 patients (11 males and 13 females) with IgA nephropathy and 22 normal controls (11 males and 11 females). The titers of IgA and IgM antibodies for E.coli and H.influenzae were significantly higher in the IgA nephropathy group than in the controls. In addition, IgA and IgM antibody titers for E.coli and H.influenzae showed a significant positive correlation with serum IgA and IgM levels. These findings suggest that subclinical infection by these bacteria stimulates IgA production and that this may be a factor in the development and progression of IgA nephropathy.

Role of neuropeptide Y and its receptor subtypes in neurogenic pulmonary edema

The effect of neuropeptide Y on the number of perivascular carbon deposits, assessed as a measure of lung vascular permeability, was examined in isolated perfused lung preparations of rats. The number of carbon particle deposits after bronchial application of neuropeptide Y was increased in a dose-dependent manner. In the presence of a beta-adrenoceptor antagonist, norepinephrine augmented the effects of neuropeptide Y. Peptide YY, an analog of neuropeptide Y, demonstrated a much lower potency for increasing the number of carbon deposits, and neuropeptide Y-(18-36), which elicits a weak antagonist action on the neuropeptide Y Y3 receptor, significantly decreased the neuropeptide Y-induced increase. Furthermore, examination of the influence of neuropeptide Y-(18-36) pretreatment on fibrin-induced neurogenic pulmonary edema, in rats, revealed a reduction of the protein concentration ratio of tracheal fluid to serum. Therefore, we conclude that neuropeptide Y may elevate vascular permeability in the pulmonary circulation, conceivably through the neuropeptide Y Y3 receptor, and that neuropeptide Y may in fact play a physiological role even in the in-situ pulmonary circulation.

Sonic spray mass spectrometry

We have developed a sonic spray ionization method, in which a methanol and water solution is sprayed from a fused-silica capillary with gas flow coaxial to the capillary. Ions as well as charged droplets are produced under atmospheric pressure, and their intensities depend on the gas flow rate (gas velocity). Positive ions produced from dilute solutions of molecules regarded as neurotransmitters, such as catecholamine, by this ionization method have been analyzed with a quadrupole mass spectrometer. The protonated dopamine molecule is detected in the spray of the 10 nM solution, and the mass spectrum is compared with that obtained by the ion spray ionization method. A comparison between the mass-analyzed ion intensity and the ion current, which represents the sum of ions and charged droplets, shows that most ions are produced from the charged droplets after spraying. Furthermore, we found that the charged droplet formation cannot be ascribed to the traditional models of friction electrification, electrical double layer, or statistical charging. An explanation is proposed based on the ion concentration distribution in a small droplet.

Effects of neuropeptide Y on lung vascular permeability in the pulmonary circulation of rats

The effects of neuropeptides on the capillary filtration coefficient in the vessels of the pulmonary circulation were examined, using isolated lung perfusion preparations from rats. Neuropeptide Y and neurokinin A elevated the filtration coefficient, and calcitonin gene related peptide diminished it. Neurotensin and substance P did not affect the value at concentrations less than 10(-7) M. The number of extravasated carbon particle deposits subsequent to tracheal application of neuropeptide Y during spontaneous respiration increased in a dose-dependent manner. From these results, we conclude that neuropeptide Y may increase vascular permeability in the pulmonary circulation.

An immunohistochemical study of extracellular matrix components and integrins in human glomerular diseases

The localization of extracellular matrix components and their cell surface receptors (integrins) was studied in 130 subjects in order to clarify their participation in the progression and aggravation of various types of nephritis. Included in the study were 2 normal subjects, 14 patients with minimal change disease, 2 patients with minimal change nephrotic syndrome, 65 patients with IgA nephropathy, 18 patients with mesangial proliferative glomerulonephritis, 15 patients with membranous glomerulonephritis, 5 patients with membranoproliferative glomerulonephritis and 9 patients with systemic lupus erythematosus (SLE). The distribution of fibronectin (FN), vitronectin (VN), laminin (LN), heparan sulfate proteoglycan (HSPG), type III, IV, V, VI collagen, fibronectin receptor (FNR) and vitronectin receptor (VNR) in the glomerulus was studied employing the indirect immunoperoxidase method. FN, LN, type IV, V and VI collagen, FNR and VNR were found to be distributed in the expanded mesangial region in IgA nephropathy, mesangial proliferative glomerulonephritis and membranoproliferative glomerulonephritis. Deposition of VN was observed in some of the patients. In membranous glomerulonephritis and membranoproliferative glomerulonephritis, the distribution of FN, LN, type IV collagen, FNR and VNR was increased in the thickened loop wall and VN deposition was also observed. Quantitative and functional changes in the extracellular matrix and integrins, therefore, appear to participate in the progression and aggravation of glomerulonephritis.

Hyperlipoproteinemia in rats fed polychlorinated biphenyls

Hypercholesterolemia due to feeding of polychlorinated biphenyls (PCB) and due to feeding of high cholesterol was compared. Rats in control group were fed a 25% casein diet, and those in PCB group or cholesterol group were fed the 25% casein diet supplemented with 0.03% PCB or 1% cholesterol and 0.25% cholic acid, respectively. Lipoprotein mass (d less than 1.21 g/ml) was higher 1.9- and 1.3-fold in rats fed PCB and cholesterol, respectively, as compared with controls. In rats fed PCB, protein, cholesterol, and phospholipid in the lipoprotein fraction markedly increased. Cholesterol-feeding resulted in the increase in pre-beta-lipoprotein cholesterol, while PCB-feeding increased alpha-lipoprotein cholesterol and slightly slow migrated pre-beta-lipoprotein cholesterol. PCB-treated rats had more apolipoprotein A-I in the lipoprotein fraction than control and cholesterol-fed rats. The data demonstrated that hyperlipoproteinemia induced by PCB is a novel alpha-lipoproteinemia and a useful model for investigating metabolism of high density lipoprotein.

Serum soluble interleukin-2 receptor in patients with glomerulonephritis

Serum soluble interleukin-2 receptor (IL-2R) concentrations were determined using the ELISA method in 55 cases of glomerulonephritis. These patients can be classified as 29 cases of IgA nephropathy, 10 cases of membranous glomerulonephritis and 16 cases of mesangial proliferative glomerulonephritis. Our results showed that serum soluble IL-2R concentrations in glomerulonephritis cases were significantly higher than those in healthy controls. Among the different types of glomerulonephritis cases, however, no significant differences in serum soluble IL-2R were observed. While we found a significant positive correlation of serum soluble IL-2R to BUN and creatinine, we also found a significant negative correlation between serum soluble IL-2R and creatinine clearance. These findings suggest that serum soluble IL-2R can serve as an indicator of exacerbation of glomerulonephritis.

Liver support system used sorbent urethane sheet embedded with powdered charcoal

Requirements to be met by an artificial liver support system are the abilities to perform the function of the liver, i.e., to support the functions of protein synthesis, detoxification, and phagocytosis. At present there are no artificial liver support that can satisfy all these conditions other than the detoxification and protein synthesis by removal and supply in plasma exchange. This mode of treatment poses various problems, including the disadvantage of requiring a great amount of plasma (1). Noting the adsorption performance of powdered charcoal, we have developed a new type of adsorbent for clinical application (UPC, BESPORE, Japan Medical Supply Co. Ltd., Hiroshima, Japan) that consists of powdered charcoal immobilized and encapsulated on a blood-biocompatible sheet. UPC is capable of purifying middle to large molecular weight and protein-bound substances, which have been relatively difficult to achieve with conventional blood purification (Fig.1).

Serum soluble interleukin 2 receptor in patients with IgA nephropathy

Serum soluble interleukin 2 receptor (IL-2 R) was determined by the ELISA method in 29 cases of IgA nephropathy and 50 healthy controls. The results showed that the value in IgA nephropathy cases was significantly higher than that in healthy controls. Furthermore, among the cases of IgA nephropathy, the value was significantly higher in the groups with hypertension, elevated serum IgA and depressed creatinine clearance than in that of the corresponding controls. These findings suggest that serum soluble IL-2 R can serve as a prognostic index of IgA nephropathy.

In vitro immunoglobulin production by peripheral blood mononuclear cells as a prognostic factor in IgA nephropathy

To determine whether immune system disorders are involved in the exacerbation of IgA nephropathy, the immunoglobulin production of peripheral blood mononuclear cells obtained from 45 IgA nephropathy patients was measured and then compared with that of healthy individuals. The level of IgA production was classified into an elevated group and a non-elevated group and comparisons were made with various clinical factors considered to be related to exacerbation of this disease. The results indicated that although there was no significant difference in immunoglobulin production of the peripheral mononuclear cells between IgA nephropathy cases and healthy individuals in the group not stimulated with pokeweed mitogen (PWM), the group stimulated with PWM revealed a production of IgA, IgG, and IgM which was significantly elevated (P less than 0.01). Also, within the group stimulated with PWM, hypertension, severe proteinuria and microscopic hematuria, elevated BUN and serum creatinine values, decreased 15-min PSP and creatinine clearance values, severe histological damage, and severe IgA deposition were observed more in the elevated IgA production group than in the non-elevated group. These findings suggest that an elevated IgA production plays an important role in the excerbation of this disease.

Development and clinical application of a new CAPD connection system--Safedap

To perform continuous ambulatory peritoneal dialysis (CAPD), a safe and easy bag exchange system must be established. The authors developed a new system called "Safedap" and applied it to clinical cases. Safedap consists of a bottom, a sleeve, a shell, and a lock-type connector. The bottom and sleeve are made into one unit with a preembedded sponge saturated with 10% povidone-iodine for disinfection and protection. Safedap was introduced to 23 patients who were observed for a period of 293 patient months. Sixteen patients used a standard spike and functioned as controls. Peritonitis rates were 1/73.3 patient months in Safedap (4 episodes in 3 patients) and 1/30.1 patient months in controls (10 episodes in 7 patients; p less than 0.05). Using life table analysis, the probability of a control being peritonitis free at 12 months was 0.63 versus 0.95 in those using Safedap (p less than 0.05). By allowing completion of bag exchanges safely and rapidly, Safedap is effective in reducing the occurrence rate of peritonitis.

Temporary liver support using a new type of sorbent. A urethane sheet embedded with powdered charcoal

A new sorbent, urethane sheet embedded with powdered charcoal (UPC, BESPORE), which had been developed for use in a temporary liver support system, has been clinically applied since 1984. This system consists of a UPC plasma-perfusion circuit (using a recirculation system) followed by a supplementary 0.8 L plasma exchange, using hemodialysis for the purpose of performing both removal and supplementary therapy at the same time. On average, approximately 40% of both bilirubin and bile acid are removed, with the osmolality gap reduced by 30%. This system is effective for prolongation of life in patients with chronic hepatic failure and those with acute hepatic failure that has become chronic. It can be considered an effective maintenance therapy for patients before liver transplantation.